Kronični dugotrajni neliječeni giht s istodobnom dilatacijskom kardiomiopatijom i iznimno opsežnom anasarkom

Gout is the most common type of inflammatory arthritis in man caused by deposition of urate crystals into the joints as the result of elevated serum urate levels. A case of a 59-year-old patient with untreated, long-lasting gout and clinical manifestation of decompensated global dilated cardiomyopathy is presented. Examination revealed generalized pitting edema extending from both lower extremities to the sacrum, abdominal, and thoracic wall, with scrotal swelling and upper extremity involvement, an exceptionally vast generalized edema, i.e. anasarca. Proximal and distal interphalangeal joints of the hands and feet were swollen and deformed, with marked yellow tophi nodules. Laboratory studies revealed high serum uric acid concentration (546 μmol/L), decreased creatinine clearance (0.8 mL/s) and albumin concentration (27.4 g/L), as well as increased total urine protein mass (0.35 g/24 h). X-rays of the affected feet and fists showed punched-out lesions of the subchondral bone with overhanging bony margins in the first metatarsophalangeal, proximal, and distal interphalangeal joints of both hands. The extreme clinical presentation resolved upon intravenous administration of diuretics and pleurocentesis, followed by oral medications including furosemide, angiotensin-converting enzyme inhibitor, spironolactone and digoxin. Since serum urate level has been identified as an independent risk factor for the development of ischemic heart and chronic kidney disease, regulation of urate concentration is necessary, especially in patients diagnosed with gout.Giht je najčešći tip upalnog artritisa, a uzrokovan je nakupljanjem kristala urata u zglobovima kao rezultat povišene razine urata u serumu. Prikazan je slučaj 59-godišnjeg bolesnika s neliječenim uričnim artritisom i kliničkom manifestacijom globalno dekompenzirane dilatacijske kardiomiopatije. Kliničkim pregledom dominirala je anasarka, tj. opsežan generalizirani tjestasti edem oba gornja i donja ekstremiteta, skrotalni otok, edem trbušne i prsne stijenke. Proksimalni i distalni interfalangealni zglobovi šaka i stopala bili su otečeni i deformirani, uz vidljive žute čvoričaste tofe. Laboratorijski testovi pokazali su visoku koncentraciju mokraćne kiseline u serumu (546 μmol/L), smanjeni klirens kreatinina (0,8 mL/s) i koncentraciju albumina (27,4 g/L), te povišenu ukupnu masu bjelančevina u mokraći (0,35 g/24 h). Rendgenske snimke zahvaćenih stopala i šaka pokazale su destrukcije i rubne uzure s uzdignućem korteksa u prvom metatarzofalangealnom, proksimalnom i distalnom interfalangealnom zglobu obiju šaka. Ova ekstremna klinička slika riješena je intravenskom primjenom diuretika i pleurocentezom, nakon čega je slijedila oralna terapija uključujući furosemid, inhibitor enzima za konverziju angiotenzina, spironolakton i digoksin. Kako su serumske razine urata utvrđene kao neovisan čimbenik rizika za razvoj ishemijske srčane i kronične bubrežne bolesti, regulacija koncentracije urata je neophodna, naročito kod bolesnika s dijagnosticiranim gihtom

Tireotoksična kriza u 75-godišnje bolesnice

A 75-year-old female patient was admitted to the Intensive Care Unit with the signs of thyrotoxic crisis. Although hyperthyroidism had been previously suspected, thyrosuppressive therapy was not initiated on time. This along with other adverse factors like acute urinary infection contributed to deterioration and unfavorable development of the disease. Clinical improvement was noticed 24 hours from the introduction of combined therapy with propylthiouracil, propranolol, hydrocortisone and cardiotonics for rapid atrial fibrillation caused by atherosclerotic and thyrotoxic heart, supplemented with sedatives and necessary medical care. Shortly upon normalization of the thyroid hormone levels, RJ therapy was administered as a final solution. Pancytopenia verified before the initiation of thyrostatic therapy also contributed to this solution. The intention of this case report is to point to the yet possible occurrence of thyrotoxic crisis, which is nowadays extremely rare owing to appropriate management of hyperthyroidism. Nevertheless, may the disease failed to be recognized on time and therapy is introduced too late, along with other unfavorable factors such as acute infection, the disease can still occur sporadically. Although the mortality rate has been drastically lowered, it is still rather high, i.e. about 7%, therefore these patients should be treated at intensive care unit.Žena u dobi od 75 godina primljena je u Jedinicu za intenzivno liječenje pod slikom tireotoksične krize. Iako se je već ranije sumnjalo na hipertireozu, tireosupresivna terapija nije započeta na vrijeme, što je uz negativne pridružene čimbenike (akutna mokraćna infekcija) doprinijelo nepovoljnom razvoju bolesti. Kombinirana terapija propiltiouracilom, propranololom, hidrokortizonom te kardiotonicima zbog brze atrijske fibrilacije u sklopu aterosklerotskog i tireotoksičnog srca, uza sedative i ostale potporne mjere dovela je do kliničkog poboljšanja već nakon 24 h. Ubrzo nakon normalizacije hormona štitnjače primijenjena je RJ terapija kao definitivno rješenje, čemu je doprinijela i pancitopenija dokazana jo. prije započete terapije tireostaticima. Ovim prikazom želi se ukazati na jo. uvijek moguću pojavu tireotoksične krize koja je danas zahvaljujući primjerenom liječenju hipertireoze izrazito rijetka, no uz neprepoznavanje bolesti i zakašnjelu terapiju te nepovoljne druge čimbenike (npr. akutni infekt) jo. se uvijek može sporadično susresti. Iako je smrtnost drastično smanjena, ipak je jo. uvijek dosta visoka i iznosi oko 7%, zbog čega i takvi bolesnici zahtijevaju smještaj u jedinice za intenzivno liječenje

S kakvim je zdravstvenim rizikom udružena amenoreja?

Amenorrhea is one of the most common symptoms in the woman’s health pathology. It can be caused by anatomical defects of the outflow tract (uterus, cervix, vagina), thus being in the gynecologist’s domain, or can be observed in gonadal dysgenesis (Turner’s syndrome), hypopituitarism (Sheehan’s syndrome), prolactin-secreting pituitary tumors, Cushing’s syndrome, hyperthyroidism, stress, anorexia nervosa, polycystic ovaries, and in women upon discontinuation of oral contraceptives, especially if they have a history of prior menstrual irregularities. Endocrine abnormalities may also be due to changes in target tissue responses to hormones. These disorders can occur by a variety of mechanisms. Endocrine glands may be injured or destroyed by neoplasia, infections, hemorrhage, autoimmune disorders, and many other causes. Menopause, pregnancy and lactation are the most common causes of ammenorrhea. Hypothalamic lesions resulting in impaired secretion of releasing hormones may manifest themselves by pituitary dysfunction, which in turn leads to functional abnormalities of its various target organs. Extraglandular disorders can result in hormone deficiency and become manifest with amenorrhea as one of the symptoms. Assessment of the patient’s endocrine status relies on the findings from the history, physical examination and laboratory testing. The latter can include measurement of hormone levels of their metabolites in plasma or urine either in basal state or in response to provocative testing. For endocrine deficiency syndromes, hormones are generally administered to counteract the deficiency. In hormone excess syndromes, a variety of approaches have been used. Hyperfunctioning tumors are removed when possible, and sometimes hyperplastic glands are extirpated. In other cases, drugs are given to block hormone production. Menopause related osteoporosis is the leading health problem associated with amenorrhea and should be treated as early as possible, i.e. from the beginning of the period of menses disappearance.Amenoreja je jedan od najčešćih simptoma u ženskoj patologiji. Ona može biti uzrokovana anatomskim nedostacima izlaznoga trakta (maternica, ušće maternice, rodnica) pa spada u djelokrug ginekologa, no može se zapaziti kod bolesti nedostatka gonada (npr. Turnerov sindrom), hipopituitarizma (npr. Sheehanov sindrom), u bolesnika s tumorima hipofize koji luče prolaktin, kod Cushingova sindroma, hipertiroze, stresa, anoreksije nervosa, policističnih jajnika, te nakon prestanka uzimanja oralnih kontraceptiva, poglavito u žena s prethodnim menstrualnim nepravilnostima u anamnezi. Endokrine abnormalnosti mogu isto tako biti uzrokovane promjenama u odgovoru ciljnih tkiva na hormone. Različiti mehanizmi mogu biti uključeni u nastanak ovih bolesti. Endokrine žlijezde mogu biti oštećene ili uništene neoplazijom, infekcijama, krvarenjem, autoimunim bolestima, te mnogim drugim uzrocima. Najčešći uzroci amenoreje su menopauza, trudnoća i dojenje. Oštećenja hipotalamusa koja dovode do poremećenog lučenja hormona za otpuštanje mogu se očitovati disfunkcijom hipofize, što opet rezultira funkcionalnim abnormalnostima različitih ciljnih organa. Poremećaji izvan te žlijezde mogu dovesti do pomanjkanja hormona i postati očitima, uz amenoreju kao jedan od simptoma. Procjena endokrinog statusa bolesnice temelji se na nalazima iz anamneze, fizikalnog pregleda i laboratorijskih pretraga. Laboratorijski testovi mogu uključivati mjerenje razina hormona ili njihovih metabolita u plazmi ili mokraći u bazalnom stanju ili u odgovoru na provokativno testiranje. Kod sindroma endokrine deficijencije hormoni se uglavnom daju kako bi se ispravila ta deficijencija. Kod sindroma s viškom hormona primjenjuju se različiti pristupi. Tumori koji pokazuju hiperfunkciju se odstranjuju kadgod je to moguće, a ponekad se uklanjanju i hiperplastične žlijezde. U drugim pak slučajevima daju se lijekovi za suzbijanje stvaranja hormona. Osteoporoza povezana s menopauzom vodeći je zdravstveni problem povezan s amenorejom i treba ju što ranije liječiti, tj. od početka razdoblja prestanka menstruacije

S kakvim je zdravstvenim rizikom udružena amenoreja?

Amenorrhea is one of the most common symptoms in the woman’s health pathology. It can be caused by anatomical defects of the outflow tract (uterus, cervix, vagina), thus being in the gynecologist’s domain, or can be observed in gonadal dysgenesis (Turner’s syndrome), hypopituitarism (Sheehan’s syndrome), prolactin-secreting pituitary tumors, Cushing’s syndrome, hyperthyroidism, stress, anorexia nervosa, polycystic ovaries, and in women upon discontinuation of oral contraceptives, especially if they have a history of prior menstrual irregularities. Endocrine abnormalities may also be due to changes in target tissue responses to hormones. These disorders can occur by a variety of mechanisms. Endocrine glands may be injured or destroyed by neoplasia, infections, hemorrhage, autoimmune disorders, and many other causes. Menopause, pregnancy and lactation are the most common causes of ammenorrhea. Hypothalamic lesions resulting in impaired secretion of releasing hormones may manifest themselves by pituitary dysfunction, which in turn leads to functional abnormalities of its various target organs. Extraglandular disorders can result in hormone deficiency and become manifest with amenorrhea as one of the symptoms. Assessment of the patient’s endocrine status relies on the findings from the history, physical examination and laboratory testing. The latter can include measurement of hormone levels of their metabolites in plasma or urine either in basal state or in response to provocative testing. For endocrine deficiency syndromes, hormones are generally administered to counteract the deficiency. In hormone excess syndromes, a variety of approaches have been used. Hyperfunctioning tumors are removed when possible, and sometimes hyperplastic glands are extirpated. In other cases, drugs are given to block hormone production. Menopause related osteoporosis is the leading health problem associated with amenorrhea and should be treated as early as possible, i.e. from the beginning of the period of menses disappearance.Amenoreja je jedan od najčešćih simptoma u ženskoj patologiji. Ona može biti uzrokovana anatomskim nedostacima izlaznoga trakta (maternica, ušće maternice, rodnica) pa spada u djelokrug ginekologa, no može se zapaziti kod bolesti nedostatka gonada (npr. Turnerov sindrom), hipopituitarizma (npr. Sheehanov sindrom), u bolesnika s tumorima hipofize koji luče prolaktin, kod Cushingova sindroma, hipertiroze, stresa, anoreksije nervosa, policističnih jajnika, te nakon prestanka uzimanja oralnih kontraceptiva, poglavito u žena s prethodnim menstrualnim nepravilnostima u anamnezi. Endokrine abnormalnosti mogu isto tako biti uzrokovane promjenama u odgovoru ciljnih tkiva na hormone. Različiti mehanizmi mogu biti uključeni u nastanak ovih bolesti. Endokrine žlijezde mogu biti oštećene ili uništene neoplazijom, infekcijama, krvarenjem, autoimunim bolestima, te mnogim drugim uzrocima. Najčešći uzroci amenoreje su menopauza, trudnoća i dojenje. Oštećenja hipotalamusa koja dovode do poremećenog lučenja hormona za otpuštanje mogu se očitovati disfunkcijom hipofize, što opet rezultira funkcionalnim abnormalnostima različitih ciljnih organa. Poremećaji izvan te žlijezde mogu dovesti do pomanjkanja hormona i postati očitima, uz amenoreju kao jedan od simptoma. Procjena endokrinog statusa bolesnice temelji se na nalazima iz anamneze, fizikalnog pregleda i laboratorijskih pretraga. Laboratorijski testovi mogu uključivati mjerenje razina hormona ili njihovih metabolita u plazmi ili mokraći u bazalnom stanju ili u odgovoru na provokativno testiranje. Kod sindroma endokrine deficijencije hormoni se uglavnom daju kako bi se ispravila ta deficijencija. Kod sindroma s viškom hormona primjenjuju se različiti pristupi. Tumori koji pokazuju hiperfunkciju se odstranjuju kadgod je to moguće, a ponekad se uklanjanju i hiperplastične žlijezde. U drugim pak slučajevima daju se lijekovi za suzbijanje stvaranja hormona. Osteoporoza povezana s menopauzom vodeći je zdravstveni problem povezan s amenorejom i treba ju što ranije liječiti, tj. od početka razdoblja prestanka menstruacije

Može li dugotrajna velika depresija izazvati osteoporozu?

A marked clinical, physiologic, and biochemical connection between osteoporosis and major depressive disorder (MDD) is described. There are numerous states and diseases associated with osteoporosis. The aim of the study was to assess the presumed association between hypercortisolism and osteoporosis. Some recent studies provided evidence for association between previous history of MDD and marked osteoporosis. In MDD, there are two well documented biochemical abnormalities, hypercortisolism and its resistance to dexamethasone suppression. The present study included 31 MDD patients (19 male and 12 female), mean age 37±1.3, age range 29-41 years, and 17 healthy male volunteers mean age 39±1.6, age range 34-45 years. The levels of free cortisol in 24-h urine, serum cortisol at 8 a.m. and 5 p.m., and cortisol in dexamethasone suppression test as well as bone mineral density were measured in all study subjects. The results obtained were analyzed by use of Spearman\u27s nonparametric rank correlation, rho=-0.805, with a statistical significance level of p<0.01 (2-tailed). Study results suggested that patients with a long-term history of depression may develop a severe form of osteoporosis. Also, a severe form of osteoporosis has been known to develop in patients with untreated Cushing\u27s syndrome.Opisana je klinička, fiziološka i biokemijska povezanost osteoporoze i velike depresije. U oba stanja dolazi do hiperaktivnostiosi HPA, sustava LC/NE, te povišenog lučenja CRH, kortizola i katekolamina. Mnoga stanja i bolesti povezane su s osteoporozom, uključujući hiperkorticizam. Novija istraživanja povezuju raniju povijest velike depresije s osteoporozom. U velikoj depresiji zabilježene su dvije biokemijske abnormalnosti: hiperkorticizam i rezistencija na supresiju deksametazonom. U naše je istraživanje bio uključen 31 bolesnik s velikom depresijom (19 muškaraca i 12 žena) prosječne dobi od 37±1,3 godine, te 17 muških dobrovoljaca u dobi od 34 do 45 godina, prosječne dobi od 39±1,6 godina. U svih je bolesnika određivana razina kortizola u 24-satnoj mokraći, serumski kortizol, kortizol u testu supresije deksametazonom, a gustoća kostiju je određivan adenzitometrijski. Bila je to skupina mlađih muškaraca i žena s održanim menstruacijskim ciklusom, u početku bez osteoporoze, ali godinama pod antidepresivnom terapijom. Analiza rezultata pokazala je povišene vrijednosti kortizola, te pojavu osteoporoze razvoj koje je bio posljedica povišene razine kortizola. U analizi rezultata primijenjena je neparametrijska korelacija rangova, pri čem je Spearmanov rho bio -0,805 uz statistiku značajnost od p<0,01. Na temelju rezultata ispitivanja zaključeno je da bolesnici liječeni zbog depresije imaju povišenu razinu kortizola u 24-satnoj mokraći. Bolesnici koji su duže bolovali od depresije imali su jače izraženu osteoporozu. Kortizol vjerojatno ima značajnu ulogu u nastanku osteoporoze u bolesnika s depresijom, a poznato je da se u bolesnika s neliječenim Cushingovim sindromom također razvija jak oblik osteoporoze

Liječenje polipa žučnoga mjehura: prijedlog optimalne strategije

Polypoid lesions of the gallbladder can be divided into benign and malignant lesions. Benign polypoid lesions of the gallbladder are divided into tumors and pseudotumors. Pseudotumors make up the majority of polypoid lesions of the gallbladder. They can occur in the form of polyps, hyperplasia or other miscellaneous lesions. Adenomas are the most common benign neoplasms of the gallbladder. Ultrasound has been demonstrated to be significantly better in detecting polypoid lesions of the gallbladder as compared with computed tomography and cholecystography. Recommendations for an optimal strategy in the management of gallbladder polyps are presented. Generally, no treatment is required in a young patient with very small gallbladder polyps, who is completely free from symptoms. In patients with unequivocal recurrent biliary colic, elective cholecystotomy is warranted, especially in case of coexistence of stones and polyps. Cholecystectomy is also indicated in patients with gallbladder polyps greater than 10 mm, irrespective of symptomatology. In patients with gallbladder polypoid lesions smaller than 10 mm, cholecystectomy is only indicated if complicating factors are present, e.g., age ³ 50 and coexistence of gallstones. If a gallbladder polyp is smaller than 10 mm and if complicating factors are absent, the “watch-and-wait” strategy seems to be recommendable.Polipoidne lezije žučnoga mjehura mogu se podijeliti u benigne i maligne. Benigne polipoidne lezije dijele se na prave tumore i pseudotumore. Pseudotumori čine većinu polipoidnih lezija žučnoga mjehura, a mogu se očitovati kao polipi, hiperplazija ili druge različite lezije. Adenomi predstavljaju najčešće benigne neoplazme žučnoga mjehura. Pokazalo se da je ultrazvuk značajno bolji u otkrivanju polipoidnih lezija žučnoga mjehura u usporedbi s kompjutoriziranom tomografijom i kolecistografijom. U ovom su radu prikazane preporuke za optimalnu strategiju praćenja i obrade polipa žučnoga mjehura. Općenito, u mladog bolesnika s polipima žučnoga mjehura manjim od 10 mm i bez simptoma nije potrebna nikakva terapija. U bolesnika s jasnim kolikama elektivna kolecistektomija je opravdana, poglavito ako su uz polipe prisutni i žučni kamenci. Kolecistektomija je također indicirana u bolesnika s polipima većim od 10 mm, bez obzira na simptomatologiju. U bolesnika s polipima manjim od 10 mm kolecistektomija je indicirana samo ako se radi o bolesnicima starijim od 50 godina i/ili ako su istodobno prisutni i žučni kamenci. Kad su polipi žučnoga mjehura manji od 10 mm i ako se radi o bolesnicima mlađim od 50 godina u kojih nije moguće dokazati žučne kamence, preporučujemo strategiju ‘pratiti i čekati’

Hrvatsko-brazilski projekt rak dojke i kliničko istraživanje kreativnih i art/suportivno-ekspresivnih oblika (psiho)terapije

This paper shows an innovative concept of a Croatian-Brazilian project in the field of psychosocial oncology and sophrology. Within this context, the paper presents the basic outline of a research protocol for conducting a transcultural study relating to the implementation of supportive-expressive arts psychotherapies providing complementary approaches to a complex treatment and rehabilitation program for breast cancer patients. Some forms of past cooperation between the Croatian and Brazilian universities, healthcare institutions and professional associations are presented with reference to the major topics discussed at the Latin American Congress of Art Therapy. This Croatian-Brazilian cooperation has been envisaged in the outline of a research project on “Supportive Therapies and Life Potential Developments” supported by the Croatian Ministry of Science.U ovom radu prikazan je inovativni koncept hrvatsko-brazilskog projekta u području psihosocijalne onkologije i sofrologije. U tom okviru prikazne su osnovne crte plana znanstvenog istraživanja za provođenje transkulturne studije koja se odnosi na primjenu art/suportivno-ekspresivnih oblika psihoterapije kao komplementarnih pristupa u kompleksnom liječenju i rehabilitaciji bolesnica s rakom dojke. U vezi s tim neki oblici dosadašnje suradnje između hrvatskih i brazilskih sveučilišnih i kliničkih institucija i profesionalnih udruga, prikazani su s osvrtom na sadržaj latinsko-američkog kongresa o art terapijama. Hrvatsko-brazilska suradnja predviđena je u sadržaju znanstvenog projekta “Suportivne terapije i razvoj životnih potencijala” koji je podržalo Ministarstvo znanosti Republike Hrvatsk

Utjecaj oktreotida na lučenje hormona rasta u bolesnika s akromegalijom

A majority of growth hormone secreting pituitary adenomas respond well to somatostatin and somatostatin analogues. The acute action of octreotide, a synthetic somatostatin analogue, on growth hormone secretion was assessed in 42 patients with clinically and laboratory verified acromegaly. Octreotide was administered subcutaneously in a dose of 50 mg. Blood sampling was performed at 1-hour intervals during 6 hours of testing. The mean basal values of growth hormone (c±SE) was 26.3±4.5 ng/ml (range 6.1-66.6 ng/ml), and of IGF-I 2940±171.7 IU/l (range 2350-4856 IU/l). Reduction in growth hormone values below 5 ng/ml was recorded in 31 (73.8%), suppression by more than 50% in 5 (11.9%) and by more than 45% in 3 (7.1%) patients. Maximal suppression was noticed in the first two hours of testing. In 3 (7.1%) patients, resistance to octreotide with no change in growth hormone values was observed. In conclusion, octreotide reduces growth hormone values in most acromegalic patients. A small proportion of acromegalic patients do not respond well to octreotide, probably due to the lack of somatostatin receptors on tumor cells. We consider the acute octreotide test as a very useful tool in triage of acromegalic patients eligible for medicamentous treatment.Većina adenoma hipofize koji luče hormon rasta zadrže osjetljivost na somatostatin i njegove analoge. Ispitivano je akutno djelovanje oktreotida, sintetskog oktapeptidnog analoga somatostatina, na razinu hormona rasta u 42 bolesnika s klinički i laboratorijski potvrđenom akromegalijom. Oktreotid je primijenjen supkutano u dozi od 50 mg. Uzorci krvi za određivanje hormona rasta uzimani su svakog sata u razdoblju od šest sati. Prosječna bazalna vrijednost hormona rasta bila je 26,3±4,5 c±SE) ng/ml (raspon 6,1-66,6 ng/ml), a IGF-I 2940,2±171,7 IJ/l (raspon 2350-4856 IJ/l). Nakon primjene oktreotida razina hormona rasta u serumu snizila se na normalne vrijednosti (<5 ng/ml) u 31 (73,8%) bolesnika, u 5 (11,9%) bolesnika nastupilo je sniženje za više od 50%, a u 3 (7,1%) za više od 45%. Maksimalno je sniženje u ovih bolesnika uslijedilo jedan do dva sata nakon početka testa. Troje (7,1%) bolesnika pokazalo je rezistenciju na oktreotid. Njihove vrijednosti hormona rasta ostale su gotovo jednake onima u bazalnim uvjetima. Zaključeno je da oktreotid normalizira razinu hormona rasta u većine akromegaličnih bolesnika, međutim, u nekih se ne postiže zadovoljavajući odgovor, vjerojatno zbog malog broja somatostatinskih receptora na membrani tumorskih stanica. Smatramo da je akutni test s oktreotidom koristan u odabiru akromegaličnih bolesnika za konzervativno liječenje analozima somatostatina

Prikaz bolesnika s ektopičnom sekrecijom ACTH i znacima Cushingova sindroma

Ectopic ACTH secretion was the first paraneoplastic endocrine syndrome described in the literature. The most common tumors associated with ectopic ACTH production are small-cell lung cancer and atypical carcinoids. High cortisol levels have also been described in patients with adenocarcinoma and large-cell carcinoma of the lung, other carcinoid tumors, thymoma, neural crest tumors, medullary carcinoma of the thyroid, and bronchial adenomas. Patients rarely live long enough for frank Cushing’s syndrome to develop. A 30-year-old male is described, who was admitted to endocrinology ward for clinical features of Cushing’s syndrome. Outpatient examination showed high levels of plasma cortisol on several occasions, without suppression of night dexamethasone test. Laboratory tests performed during his hospital stay showed an increased level of serum cortisol without suppression of night dexamethasone test, increased level of ACTH, and decreased testosterone level, increased 17 OHCS in urine. CT scan of adrenal and pituitary glands, and chest x-ray were normal. The patient was discharged with an appointment made for surgical exploration of the pituitary gland. Transnasal selective partial hypophysectomy was performed, however, excisional biopsy showed no microadenoma while the symptoms persisted postoperatively. The patient received TCT hypophysis in a maximal dose, and elevated ACTH level was found to persist after 37 days of treatment. One year later, the patient was readmitted for persistent cushinoid appearance. After complete investigations for ectopic ACTH secreting tumor, chest x-ray showed an infraclavicular, circular, sharply demarcated inhomogeneous lesion of the left lung, 2x3 cm in size. Three months later, lobectomy was performed and pathohistologic examination pointed to a carcinoid (argentaffinoma). During hospitalization, the symptoms of Cushing’s syndrome regressed. In conclusion, CRH test which usually distinguishes between hyperadrenocorticism associated with ectopic ACTH secretion and hypersecreting adrenal tumors is sometimes misleading because of the large overlap in normal and abnormal responses. In this case, chest or abdominal CT scan or MRI should be performed, because these are the most common sites of ectopic ACTH secreting tumors.Prvi paraneoplastični endokrini sindrom opisan u literaturi bila je ektopična sekrecija ACTH. Najčešći tumori udruženi s ektopičnom sekrecijom ACTH su mikrocelularni karcinom pluća i atipični karcinoidi. Visoke razine kortizola opisane su i u bolesnika s adenokarcinomom i karcinomom velikih stanica pluća, karcinoidima, timomom, tumorima neuralnog grebena, medularnim karcinomom štitnjače i bronhalnim adenomom. Bolesnici rijetko žive dovoljno dugo da razviju manifestan Cushingov sindrom. Opisan je slučaj 30-godišnjeg muškarca koji je primljen na odjel s kliničkim znacima Cushingova sindroma. Ambulantno ispitivanje pokazalo je u više navrata visoke razine kortizola koji se nije snižavao u kratkom deksametazonskom testu. Tijekom boravka u bolnici je uz već navedeno uočena visoka razina ACTH, sniženi testosteron i povišen 17 OHCS u mokraći. CT nadbubrežnih žlijezda i Rtg snimka prsnog koša bili su uredni. Bolesnik je otpušten uz dogovor za kiruršku eksploraciju hipofize, te je učinjena transnazalna djelomična hipofizektomija. Ekscizijska biopsija nije pokazala znakove tumora, a klinički znaci Cushingova sindroma ustrajali su nakon operacije. Bolesnik je podvrgnut radioterapiji hipofize u maksimalnoj dozi, međutim, vrijednosti ACTH su još uvijek bile povišene. Nakon godinu dana bolesnik je ponovno primljen na odjel zbog ustrajnih znakova Cushingova sindroma. Nakon potpune obrade u smislu traženja ektopične sekrecije ACTH, snimka prsnoga koša pokazala je infraklavikularno oštro ograničenu, nehomogenu sjenu u plućima, veličine 2x3 cm. Tri mjeseca kasnije učinjena je lobektomija, a patohistološki nalaz je ukazao na karcinoid (argentafinom). Tijekom hospitalizacije simptomi Cushingova sindroma su se povukli. U zaključku, CRH test koji obično razlikuje hiperadrenokorticizam udružen s ektopičnom sekrecijom ACTH i hipersekreciju iz adrenalnih tumora, ponekad je neprikladan zbog značajnog preklapanja u normalnom i abnormalnom odgovoru. U tom slučaju, nužan je detaljan pregled prsnoga koša i trbuha, budući da su to najčešća sijela tumora koji ektopično izlučuju ACTH

Hrvatsko-brazilski projekt rak dojke i kliničko istraživanje kreativnih i art/suportivno-ekspresivnih oblika (psiho)terapije

This paper shows an innovative concept of a Croatian-Brazilian project in the field of psychosocial oncology and sophrology. Within this context, the paper presents the basic outline of a research protocol for conducting a transcultural study relating to the implementation of supportive-expressive arts psychotherapies providing complementary approaches to a complex treatment and rehabilitation program for breast cancer patients. Some forms of past cooperation between the Croatian and Brazilian universities, healthcare institutions and professional associations are presented with reference to the major topics discussed at the Latin American Congress of Art Therapy. This Croatian-Brazilian cooperation has been envisaged in the outline of a research project on “Supportive Therapies and Life Potential Developments” supported by the Croatian Ministry of Science.U ovom radu prikazan je inovativni koncept hrvatsko-brazilskog projekta u području psihosocijalne onkologije i sofrologije. U tom okviru prikazne su osnovne crte plana znanstvenog istraživanja za provođenje transkulturne studije koja se odnosi na primjenu art/suportivno-ekspresivnih oblika psihoterapije kao komplementarnih pristupa u kompleksnom liječenju i rehabilitaciji bolesnica s rakom dojke. U vezi s tim neki oblici dosadašnje suradnje između hrvatskih i brazilskih sveučilišnih i kliničkih institucija i profesionalnih udruga, prikazani su s osvrtom na sadržaj latinsko-američkog kongresa o art terapijama. Hrvatsko-brazilska suradnja predviđena je u sadržaju znanstvenog projekta “Suportivne terapije i razvoj životnih potencijala” koji je podržalo Ministarstvo znanosti Republike Hrvatsk